Working at the heart of their communities, Yorkshire and Humber GPs witness the effects of poverty on their patients’ health every day. Working with practice teams, and increasingly the voluntary sector, GPs try to ameliorate the social determinants of health for the vulnerable and socially excluded. Unemployment remains high in this area because the textile, mining, and steel industries, which employed many of the region’s 5 million or so residents in the past, have gradually died off. Substantial numbers of the oldest and youngest in the region are living in poverty: 23% of children and 20% of older people compared with the national averages of 4.9% and 7.4%, respectively.1 Deprivation is concentrated in the major urban centres of Bradford, Leeds, Hull, and Sheffield, alongside pockets of destitution in the former mill towns of West Yorkshire and some rural areas: some of the poorest communities in Europe can be found in our region.

Marmot has confirmed the impact of deprivation on health and life expectancy through the social gradient theory.2 Sadly there are numerous examples to illustrate this from our region. For example, if you hop on the number 83 bus in the leafy south west of Sheffield and travel northwards, the life expectancy of women quickly drops by 10 years.3 In Hull there are life expectancy gaps of 12 years for men and 11 years for women between the richest and poorest.4 Rates of premature mortality from coronary heart disease are more than double in deprived areas of Sheffield compared with affluent counterparts.5 The contrast in life expectancy and health in relation to poverty can only be described as unjust and immoral.

In 2009 Glasgow University’s Professor Graham Watt used the metaphor of a swimming pool to represent both the social gradient and increased workload for GPs working in more deprived areas; in response to this he founded the Scottish ‘Deep End’ group.6 Since then, Scottish researchers have confirmed a flat distribution of funding for general practice despite the increased clinical workload when serving more deprived communities;7 multimorbidity and complex psychological and social problems increase hand in hand with deprivation.8 One estimate from Tower Hamlets shows that funding would need to be 33% higher in deprived areas if it were to be fair in consideration of the greater workload.9 Hence, GPs struggling at the Deep End have less chance of touching the bottom,6 resulting in higher levels of stress8 and ‘burnout’.10

Inspired by the Scottish group we formed ‘General Practice at the Deep End: Yorkshire and Humber’ in parallel with other groups forming in Dublin and Sydney. So far our group has been generously funded by Health Education England (HEE) Yorkshire and Humber, as part of the latter’s efforts to improve recruitment and retention of GPs in deprived areas. There are already fewer GPs per capita than in more affluent areas and a higher proportion of older GPs at risk of imminent retirement.11 An audit of training capacity in the region has revealed fewer training practices in Deep End settings, compared with Yorkshire and Humber as a whole.

FIRST MEETINGS

In autumn 2015 we identified the 100 practices with the highest deprivation scores in Yorkshire and Humber, and invited them to our first meeting; we also invited GP trainers who would be willing to support training in Deep End areas or with marginalised groups. We first met in October 2015 in Pontefract and welcomed 11 Deep End GPs to listen to the story of the original Scottish Deep End group from Professor Una Macleod. We also explored what GPs’ vision would be for a Yorkshire and Humber Deep End group.

There was an overwhelming desire to reduce health inequity and for the group to:

help with workforce and recruitment;

provide educational sessions relevant to Deep End work;

advocate for communities and to develop networks for Deep End practitioners and provide a forum to share ideas on planning services and strategy; and

link with academic research communities to evaluate the effects of interventions, gain funding, and facilitate organisation and recording of events.

This was followed up by a symposium in Wetherby in March 2016 where we heard a passionate fusion of narratives and evidence. Here, frontline GPs, nurses, researchers, educators, a director of public health, and contributions from the audience of 64 delegates created an atmosphere of hope in this often depressing era of austerity and fear.

Considering the personalities of GPs who work with the most vulnerable patients in our region, it was not surprising the room buzzed with ideas and enthusiasm; GPs were keen to collaborate with researchers and educationalists who were also passionate about finding practical solutions to the complex challenge of redressing health inequity. A full report and feedback from the day can be found on our blog (https://yorkshiredeependgp.org/) and a summary of ideas from delegates can be found in Box 1.

The Yorkshire and Humber Deep End logo. Inspired by the Scottish Deep End work, the logo represents the deep end of a swimming pool to reflect the social gradient in health; the subsequently increasing need associated with increased deprivation; and the flat distribution of funding. The green represents the rurality of Yorkshire and the blue of the Humber coastline, with a rose to unify the two.

Box 1.

What did the Yorkshire and Humber Deep End GPs say? The WEAR themes

Advantages

Disadvantages

Workforce

Simplify the process of becoming a Deep End training practice with support from established trainers and teams.

Work with patient participation groups to facilitate community empowerment and awareness.

Collaborate with CCGs to reduce health inequity and explore possibilities of developing performance indicators relevant to the Deep End.

Research

Develop a programme of research relevant to Deep End GPs to improve patient care including: barriers to self-care, access to preventive medicine at the Deep End; evaluate and describe innovations and services, for example, interpreting, social prescribing, case management, and care for patients with complex needs.

Explore and document the experiences and attitudes of GPs and trainees working at the Deep End.

WHAT NEXT?

Workforce, Education, Advocacy, and Research (WEAR) were identified as the key areas (Box 1) by Deep End GPs in Yorkshire and Humber on which to focus our efforts. HEE continues to fund us and we envisage the Deep End group acting as a catalyst to support innovative models for both under- and postgraduate training, promoting recruitment and retention into our most socially-deprived and under-doctored areas. Trainees will have the opportunity to work with marginalised groups through placements modelled on those offered by the North Dublin City GP training scheme led by Austin O’Carroll (http://www.healthequity.ie/). At the same time we are working to ensure that all trainees in Yorkshire and Humber experience tutorials in health inequalities and the social determinants of health to gain the knowledge and skills to tackle these at multiple levels. Sheffield has recently launched a popular 4-week social accountability placement for students and has approved the appointment of a clinical teaching fellow to support the expansion of current undergraduate placements in more deprived areas.

We are creating three geographical professional development hubs in South Yorkshire, West Yorkshire, and Hull/North Lincolnshire and East Yorkshire Coast, with the help of the 25 Deep End GPs who volunteered to steer the group. We will host regular local meetings for Deep End GPs and offer two region-wide conferences a year. The following topics were identified for CPD sessions: health literacy, social prescribing, advocacy, media relations, resilience, and asylum and benefits system updates. Through establishing the group and its blog we have created a real and online network that offers support to GPs under the greatest strain.

We envisage the Deep End in Yorkshire and Humber as more than just an educational or peer support group: this is a ‘movement’ reacting to the unfairness of health inequity. We will act as advocates, raising the issues of those who have the quietest voices with policymakers and CCGs. This is a movement to inspire others and to act as a catalyst for change not only in our region but also potentially nationwide.

The challenges of research at the Deep End are many but we are working up a number of research questions inspired by Deep End GPs to improve patient care. We will be developing the research with six medical students and two leadership fellows over the next year. We will also be reporting on the Yorkshire and Humber Deep End story and describing the impact of clinical and educational innovations along the way.

Working systematically and collaboratively to support Deep End GPs through the four themes of workforce, education, advocacy, and research, we are striving as a team to take heed of the take-home message at our Wetherby meeting: ‘Health is a human right: do something, do more, do it better.’12

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